Assessment 4: Fundamentals of Nursing (NURS 100) 2026 – WCU
1. Which phase of the nursing process involves the systematic collection and
verification of data?
A. Assessment
B. Implementation
C. Planning
D. Diagnosis
Answer: A
Rationale: Assessment is the first step of the nursing process, where data is gathered to
identify patient needs and health status.
2. When assessing a patient’s radial pulse, which technique is most appropriate
for a regular rhythm?
A. Count for 15 seconds and multiply by 4
B. Count for a full minute
C. Count for 30 seconds and multiply by 2
D. Use the thumb to feel the pulse
Answer: C
Rationale: For a regular rhythm, counting for 30 seconds and doubling the result is
standard. If irregular, a full minute is required.
,3. The nurse is preparing to provide oral care to an unconscious patient. Which
position is safest to prevent aspiration?
A. High Fowler’s position
B. Supine with head of bed flat
C. Side-lying (Sims) position
D. Trendelenburg position
Answer: C
Rationale: The side-lying position allows secretions to drain out of the mouth by gravity,
reducing the risk of aspiration in an unconscious patient.
4. Which principle of ethics refers to the nurse’s obligation to do no harm?
A. Non-maleficence
B. Autonomy
C. Justice
D. Beneficence
Answer: A
Rationale: Non-maleficence is the ethical principle of ‘do no harm.’
5. A nurse observes a reddened area on a patient’s sacrum that does not blanch
when pressed. What stage is this pressure injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Unstageable
Answer: A
Rationale: Non-blanchable erythema of intact skin is the hallmark of a Stage 1 pressure
injury.
, 6. Which of the following is considered a subjective data point?
A. Blood pressure of 140/90
B. A patient reporting a headache
C. Weight gain of 2 pounds
D. A localized skin rash
Answer: B
Rationale: Subjective data is what the patient says or feels, whereas objective data is
observed or measured by the nurse.
7. In the chain of infection, what is the ‘reservoir’?
A. The path by which a pathogen leaves the host
B. The method of transmission
C. The person who is susceptible to infection
D. The place where the pathogen lives and grows
Answer: D
Rationale: The reservoir is the natural habitat of an infectious agent where it lives and
multiplies.
8. Which of the ‘Rights’ of medication administration is being verified when the
nurse checks the patient’s ID band?
A. Right Route
B. Right Patient
C. Right Documentation
D. Right Time
Answer: B
Rationale: Checking the ID band and asking for the patient’s name/DOB ensures the Right
Patient.
1. Which phase of the nursing process involves the systematic collection and
verification of data?
A. Assessment
B. Implementation
C. Planning
D. Diagnosis
Answer: A
Rationale: Assessment is the first step of the nursing process, where data is gathered to
identify patient needs and health status.
2. When assessing a patient’s radial pulse, which technique is most appropriate
for a regular rhythm?
A. Count for 15 seconds and multiply by 4
B. Count for a full minute
C. Count for 30 seconds and multiply by 2
D. Use the thumb to feel the pulse
Answer: C
Rationale: For a regular rhythm, counting for 30 seconds and doubling the result is
standard. If irregular, a full minute is required.
,3. The nurse is preparing to provide oral care to an unconscious patient. Which
position is safest to prevent aspiration?
A. High Fowler’s position
B. Supine with head of bed flat
C. Side-lying (Sims) position
D. Trendelenburg position
Answer: C
Rationale: The side-lying position allows secretions to drain out of the mouth by gravity,
reducing the risk of aspiration in an unconscious patient.
4. Which principle of ethics refers to the nurse’s obligation to do no harm?
A. Non-maleficence
B. Autonomy
C. Justice
D. Beneficence
Answer: A
Rationale: Non-maleficence is the ethical principle of ‘do no harm.’
5. A nurse observes a reddened area on a patient’s sacrum that does not blanch
when pressed. What stage is this pressure injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Unstageable
Answer: A
Rationale: Non-blanchable erythema of intact skin is the hallmark of a Stage 1 pressure
injury.
, 6. Which of the following is considered a subjective data point?
A. Blood pressure of 140/90
B. A patient reporting a headache
C. Weight gain of 2 pounds
D. A localized skin rash
Answer: B
Rationale: Subjective data is what the patient says or feels, whereas objective data is
observed or measured by the nurse.
7. In the chain of infection, what is the ‘reservoir’?
A. The path by which a pathogen leaves the host
B. The method of transmission
C. The person who is susceptible to infection
D. The place where the pathogen lives and grows
Answer: D
Rationale: The reservoir is the natural habitat of an infectious agent where it lives and
multiplies.
8. Which of the ‘Rights’ of medication administration is being verified when the
nurse checks the patient’s ID band?
A. Right Route
B. Right Patient
C. Right Documentation
D. Right Time
Answer: B
Rationale: Checking the ID band and asking for the patient’s name/DOB ensures the Right
Patient.
